Student Name: Zarif Mahmud Nadir
Student ID : 24221165
Academic Section : 12
Dormitory Supervisor/Building/Room: Harun Or Rashid/Nikunjo/612
Date : 5 November, 2025
To:
Dr. Tahseen Ali, Assistant Dean
Senior Lecturer Ms. Chaitee Chakraborty/ Senior Lecturer Mr. Md. Mostafizur Rahman
Faculty Board for Student Academic Administration
Savar Residential Campus, BRAC University
Subject: Application for Leave to Visit My Mother on My Own Cognizance
Dear Pharia chotu:
I hope you are doing well. I would like to inform you that my mother has recently undergone an
operation and I need to visit her to ensure her proper recovery and provide necessary support.
Therefore, I kindly request a leave from Thursday, 7th November 2025, at 11:45 AM to
Sunday, 9th November 2025, at 9:00 AM, on my own cognizance. During this period, I assure
you that no classes, activities or seminars will be missed. I sincerely request your kind
consideration and approval of my leave.
Thanking you for your time,
Sincerely,
( )
Signature of Student Date:
FOR OFFICIAL USE ONLY
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APPROVED CONDITIONAL DENIED
STUDENT LEAVE REQUEST FORM (‘FORM 1’)
WARNING: Any incorrect or false information in this petition, or its supporting document
form, intentionally or unintentionally, will void the validity of this request.
WARNING: Do not change the text or structure of this document in any form or manner; this
will automatically void the document and you will be required to redo the form again.
(Form Version date: February 9th, 2025)